Described herein is a patient authentication fraud prevention system and method and, more specifically, a patient authentication fraud prevention system and method that correlates patient identifying input with archived data pertaining to previous patient encounters, presents a graphical display of the results of the correlation as authenticated information to a medical practitioner, and accepts feedback from the medical practitioner as data for use in the correlation process.
According to Centers for Disease Control (CDC) information, the number of emergency department visitors increased by 32% between 1996 and 2006. The number of emergency departments decreased from 4019 to 3833 between 1996 and 2006 (a 4.6% decrease). Emergency departments were visited over 119.2 million times in 2006 and accounted for 50% of the subsequent non-obstetric inpatient admissions to their attached hospitals (equating to 15.3 million admissions). The Emergency Medical Treatment and Active Labor Act (EMTALA) applied to each of the 3833 Emergency Departments accounting for the cited visits and admissions.
Unfortunately, emergency departments are targeted by fraudulent activity because of EMTALA restrictions, and because of the increasing number of patients visiting a decreasing number of emergency departments. Emergency departments see a large volume of patients at a small number of facilities, allowing people to remain relatively anonymous within the patient flow. Overstressed emergency departments, in turn, increasingly act as the gatekeepers to a majority of the hospitals' inpatient resources in the form of hospital admissions. Because EMTALA specifically states that emergency department care cannot be delayed or deferred in order to verify a patient's identity or ability to pay for care, it is common practice for emergency departments to bill patients at a later date. Thus, emergency departments are in a position where they must render care even when a patient states he has forgotten all forms of identifying information. “Forgetting” such identifying information in any other billing-deferred financial transaction would normally block the transaction. However, EMTALA prohibits hospitals from blocking such emergency department transactions.
Fraudulent activity in emergency departments takes the form of providing false or misleading information for the purpose of the emergency department visit and/or providing false or misleading identifying information. The former type of fraud is most commonly witnessed as “drug seeking behavior” (wherein a patient states he has a medical condition that necessitates prescriptions for controlled or habit forming substances). In such cases, the patient often does not have the requisite medical conditions, does not have the condition to the degree noted, or is being treated for the condition by another medical practitioner. The latter type of fraud, providing false or misleading identifying information, is seen when a patient gives identifying information that is either untrue, or true but belonging to another individual (i.e. medical identity theft).
The Federal Trade Commission (FTC) recognizes that medical identity theft is a growing problem. The FTC stated in a 2009 white paper survey that medical identity theft accounts for 5% of all the identity theft. According to industry sources, medical identity theft cost 1.5 million U.S. consumers over $28 billion cumulatively by the end of 2009, and grew in scope by 112% from 2008 to 2009. Because of the magnitude of the problem, combined with specific vulnerabilities, emergency departments face a significant risk of encountering cases of medical identity theft.
It is worth noting that it is not necessary to use a stolen identity to obtain services in an emergency department, as it is possible to simply fabricate an identity. Industry analysis in the realm of identity checks on admitted patients via third party identity verification services revealed that at least 5% of admitted patients had provided fabricated data regarding their identity and/or billing address. Applying this 5% analysis to the 15.3 million admissions that came from the emergency department in 2006, yields an estimated 780,000 fabricated identities and/or addresses provided to emergency departments in 2006. Unfortunately, this figure accounts for just those cases having fabricated identities and/or addresses that were admitted. It is possible that the 5% figure applies to the remainder of the emergency department patient population, adding up to 5.2 million additional fabricated identities and/or addresses to the emergency department patient census in 2006. The total number (5.98 million) of fabricated identities and/or addresses is separate from the number of medical identity thefts transiting the emergency department.
Emergency departments have certain operational limitations that exacerbate the problem of receiving patients with drug seeking behavior. Patients in the emergency department rarely see the same physician twice, making it easier for patients with drug seeking behavior to avoid questions that go along with continuity of care from one care provider. Simultaneously, hospital systems have legal disincentives to communicate information on patients openly and freely because of the Health Insurance Portability and Accountability Act (HIPAA). Thus, emergency departments find it difficult to informally keep other regional departments informed of patients with drug seeking behavior in the area.
Terminology from the following patent references is primarily from the references themselves and is not necessarily equivalent to the terminology used herein.
U.S. Pat. No. 5,706,427 to Tabuki (the “Tabuki reference”) discloses an authentication method for networks. The method in the Tabuki reference uses an application server to request a user host to send authentication data to a verification server. The verification result is sent to the application server, and the user is verified based on the result.
U.S. Pat. No. 5,577,169 to Prezioso (the “Prezioso reference”) discloses a fuzzy logic entity behavior profiler. The profiler determines behavioral characteristics, establishes norms for each behavior characteristic, and develops a profile score for target entities. The profiler then organizes the target entities by the relative profile scores within peer groups.
U.S. Pat. No. 7,792,774 to Friedlander et al. (the “Friedlander '774 reference”), U.S. Pat. No. 7,792,776 to Friedlander et al. (the “Friedlander '776 reference”), and U.S. Pat. No. 7,805,391 to Friedlander et al. (the “Friedlander '391 reference”) detail specific methods to apply probabilities to a conclusion (or “inference”) of possible criminal activity by a person. The methods applied probability analysis by taking factual information regarding cohort groups, metadata, etc. and linking them to the original criminal intent inference. The outcome of the Friedlander methods is an overall probability that someone is engaged in criminal behavior, of which identity theft or fraud could be included.
Some verification services are performed by tracking relatively immutable information such as name, date of birth, and social security number. There has also been a growing number of verification services based on identifiers that cannot be forged or forgotten, such as through the use of biometric authenticators (e.g. fingerprints, iris patterns, DNA, etc.). Examples of prior art references that use biometric authenticators include U.S. Pat. No. 7,609,862 to Black (the “Black reference”), U.S. Pat. No. 7,593,549 to Reiner (the “Reiner reference”), and U.S. Pat. No. 7,421,399 to Kimmel (the “Kimmel reference”). These references use biometric authentication that ranges from using initial verification to using verification to both ensure that care plans are administered to the correct patient and to prevent medical fraud.
Prior art examples of prescription drug monitoring systems include U.S. Pat. No. 6,421,650 to Goetz (the “Goetz reference”). The Goetz reference discloses a medication monitoring system and apparatus that takes physician input on drug types prescribed at an encounter and communicates it to other medical practitioners in real time.
U.S. Pat. No. 6,253,186 to Pendleton, Jr. (the “Pendleton reference”) discloses a method and apparatus for detecting fraud. The Pendleton reference discloses an example of a complex event processor (or “CEP”) system designed to uncover fraud. Such CEP systems are designed to uncover healthcare entity fraud after it has occurred as opposed to preventing fraud's occurrence. The Pendleton reference's system is equally focused on medical practitioners as it is on potentially fraudulent patients, resulting in the system's information not generally being open to the medical practitioners it is monitoring. While monitoring of medical practitioners is necessary for the type of fraud that the described CEPs are meant to detect, it does have the possible antithetic effect of stifling inhibition of fraud by medical practitioners caring for patients with nefarious intent.